Hepatocellular Carcinoma

Abstract

• Hepatocellular carcinoma (HCC) is the 5th most common cancer worldwide, with the third highest incidence of cancer-related death. In Asia and Africa, chronic hepatitis B viral infection is the leading cause of HCC, while hepatitis C viral infection predominates in Europe, Japan, and North America.

• Common sites of metastasis include other parts of the liver, abdominal lymph nodes, peritoneum, bone, and lung.

• Approximately 60–80% of patients with HCC have underlying cirrhosis of the liver. High-risk patients are screened with liver ultrasound and alpha-fetoprotein (AFP) levels for 6–12 months.

• HCC patients are often asymptomatic; when symptoms develop, they often include upper abdominal pain, weight loss, malaise, jaundice, and anorexia.

• Imaging studies can often confirm the diagnosis of HCC, without a tissue biopsy, because these lesions are hypervascular and will demonstrate a classic pattern with intense uptake on arterial phase scanning, followed by contrast washout in the delayed venous phase.

• A nodule in the 1- to 2-cm range can meet criteria for HCC if it demonstrates classic arterial enhancement on two imaging modalities such as triphasic computed tomography/magnetic resonance imaging (CT/MRI). If a lesion >2 cm shows classic enhancement on one modality, that is sufficient. A tissue biopsy should be considered if there are no classic imaging findings.

• At least 12 staging systems exist for HCC (e.g., tumor, node, metastasis [TNM], Okuda, Barcelona).

• Surgical resection or transplantation off ers the best chance of cure for HCC, but most patients are not eligible. Transplant series show 4-year recurrence-free survival rates in the range of 92%; resection series show 5-year survival rates up to 70%, but most patients develop recurrence.

• Strategies for bridge to transplant or palliation include embolization (chemo-/radio-/or bland), radiation therapy (3D-conformal radiation including image-guided intensity-modulated radiation therapy, stereotactic body radiosurgery, or protons/charged particles) and targeted therapies (sorafenib).